Ph: 1300 944 936 Fax: 1300 944 932 admin@whizdom.com.au

PO Box 7112 Kaleen ACT 2617 www.whizdom.com.au ABN 52 119 884 945

V: August 2019

Part A – Description of Injury, incident, near miss or hazard

Date of occurrence: _____________________________ Time of occurrence: __________________________ Date Reported: _____________________________ Time Reported: ______________________________ Person reporting: _____________________________ Contact details: ______________________________ Business Address: ___________________________________________________________________________________________ Location – specifics (e.g. office, on the way to work etc.): __________________________________________________________ Detailed description of the injury, incident, issue or near miss: ______________________________________________________ Near miss, issue, incident action taken (e.g. notified maintenance): ______________________________________________

Part B (injuries only) – Injured Person Details Contractor Employee Visitor Client Volunteer Department: ____________________________________ Team: ____________________________________________ Surname: ______________________________________ _ Given Names: _____________________________________ Gender: Male Female Work Role: _____________________________________ Date of Birth: _____________________________________ Contact Telephone Number(s): _______________________ Work Phone: _______________________________________ Residential or Business Name/Address: __________________________________________________________________________ Signature of injured person (if available): _________________________________________________________________________

Nature of injury

Fractures Sprain, strain of joints and adjacent muscles Superficial injury

Back injury Internal injury of chest Foreign body in eye, ear, nose or other

Back injury Poisoning and toxic effects of substances Other and unspecified injuries (must specify)

Dislocation Burns ___________________________________________

WHS INCIDENT REPORT REGISTER (injury, incident, near miss, hazard)

Report all serious incidents/injuries immediately to the safety officer and your Whizdom Account Manager - If safe to do so isolate the area and do not clean up location of injury

Part A – D Completed by person reporting an injury, incident, issue, near miss in conjunction with immediate Supervisor and the First Aid or Safety Officer. Submit completed form to Whizdom – admin@whizdom.com.au

Part E – F Completed by investigating officer (usually organised by the Whizdom Contractor Care Manager)

State the facts Do not offer opinions on responsibility for the incident

Send completed form to admin@whizdom.com.au

Report for an: Hazard Injury/ Illness Incident Near Miss

Location of injury Mark areas of the body impacted by injury:

01 Eye

02 Ear

03 Face

04 Head (other than eye, ear, face)

05 Neck

06 Back

07 Trunk (other than back and excluding internal organs)

08 Shoulders and Arms

09 Hands and Fingers

10 Hips and Legs

11 Feet and Toes

12 Internal organs (located in the trunk)

98 Multiple locations (more than one of above)

99 General and unspecified locations (e.g. skin, disease, mental disorder)

Part C – Injury Treatment and Incident Reporting

Treatment provided to injured/ill person (mark all that apply):

Treated by first aid Referred to doctor Unfit for work/returned home

Returned to work/class Referred to hospital Returned to alternative duties

Transported to doctor or hospital? Yes Hospital: _____________________________________________

No Doctor’s Surgery: _______________________________________

Description of first aid treatment given: __________________________________________________________________________ First aid provided by: _________________________________________________________________________________________ Injury, incident, near miss or issue reported to: Name: Contact No: Job Title:

Person in Charge of Team/Area: Name: Contact No: Job Title:

Witness: Name: Contact Details: Address:

Witness: Name: Contact Details: Address:

Part D – Additional Information Next of kin notified? Yes No

Detail of who was notified, time and comments:

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Additional comments (witness, details, etc.):

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Client Safety Officer contacted: Yes No Signatures Person Reporting the Incident Print Name: Signature: Date:

Manager/Director/Supervisor Print Name: Signature: Date:

* Please return the completed WHS Incident report to admin@whizdom.com.au attention Contractor Care Manager

Part E – Investigation Details

WHS Investigation Report

Initial Incident Follow Up N/A Yes No

Person/s involved in the incident/event were:

Qualified / competent to undertake the work?

Adequately supervised?

Using safe equipment (i.e. not damaged or defective

Wearing all necessary personal protective equipment

Working as per documented standard methods (i.e. SOPs, JSEA, SWMS)?

The work environment was:

Clean, uncluttered and clear of obstructions?

Adequately lit?

Well ventilated?

Not a confined area?

Able to be easily and safely accessed?

To be completed by the Contractor Care Manager with Client contact (Manager/Safety Officer/HR)

CLASS A - completed by Contractor Care Manager with Client Safety Officer CLASS B completed by Contractor Care Manager with Client Safety Officer Definition

Action

Definition

Action

Serious injury – fatal or non-fatal Dangerous incident Work caused illness Serious electrical incident

Remove/isolate risk/hazard if safe to do so Immediately notify Client and Panel Cordon off area

Significant Injury Significant near miss or issue

Investigate within 2 working days Notify Client Safety Officer onsite

CLASS C completed by Contractor Care Manager with Client Safety Officer

CLASS D completed by Contractor Care Manager with Client Safety Officer

Definition

Action

Definition

Action

Minor injury or incident Minor near miss or issue

Investigate within 3 working days Psychological–related incident/injury/issue

Notify Client and HR Operations for the client Investigation and management of the

issue/EAP services to be recommended Mechanism of Injury

01 Fall from height 07 Long term exposure to sounds 13 Exposure to radiation 19 Slide or cave-in

02 Fall on same level (incl slips, trips) 08 Exposure to variations in pressure

(other than sound) 14 Single contact with chemical or

substance 20 Vehicle accident

03 Hitting objects with part of body 09 Repetitive movement - low muscle

loading 15 Long-term contact with chemical or

substance 98 Other and multiple mechanisms of injury

04 Exposure to mechanical vibration 10 Other muscular stress 16 Other contact with chemical or

substance (includes insect/ spider bites/stings)

99 Unspecified mechanisms of injury

05 Being hit by moving objects 11 Contact with electricity 17 Contact/exposure – biological

hazards (e.g. sewage) ____________________________________

06 Exposure to sharp, sudden sound 12 Contact/exposure to heat/cold 18 Exposure to mental stress ___________________________________ Agency of Injury

01 Machinery and fixed plant 07 Non-powered equipment

13 Underground environments 98 Other agencies

02 Mobile plant 08 Chemicals

14 Live animals 99 Unspecified agencies

03 Road transport 09 Non metal substances (e.g. gas)

15 Non-living animals ___________________________________

04 Other transport 10 Other materials, substances or objects

16 Human agencies ___________________________________

05 Powered equipment, tools, appliance 11 Outdoor environment 17 Biological agencies

___________________________________

06 Non-powered hand tools 12 Indoor environments 18 Non-physical agencies

Work Related Non-Work Related Risk Rating: Low/Moderate/High/Catastrophic Escalated to Panel: Yes/No

Investigation Report A comprehensive investigation for all A and B incidents will be conducted and report submitted to Client and Panel 1. What was happening at the time of the incident/near miss or what was the injured person doing at the time of the incident?

(e.g. driving forklift, lifting transmission, typing etc)

2. What happened unexpectedly? (include name of chemical, produce, process or plant/equipment involved – e.g. brakes failed on forklift, slipped on wet floor, jack collapsed, arm started hurting while typing)

3. How did the incident/near miss occur or how was the injury/disease sustained? (include the name of any chemical, product,

process or plant/equipment involved – e.g. hit head on cabin of forklift, lacerated knee when landing on ground, arm hurt after long period of typing)

4. Consultation process and persons (include client safety officer, manager, employees and contractors, Whizdom staff etc.) 5. What were the underlying factors which caused the incident, injury or near miss?)

Contributing Factors Root Causes

Part F – Corrective Actions

Action to be Taken Timeframe Accountable person /

team

Status of action Comments

Comments: __________________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

Investigating Officer: ________________________________ Signature: ________________________________________ Position: __________________________________________ Date: ____________________________________________ Completed incident reports will be saved in the Whizdom WHS Reported Incidents file, this information will be kept confidential but may be used for reporting purposes when investigating WHS in the workplace.